The Center for Hunger-Free Communities

Solutions Based on Science and the Human Experience

Peer-reviewed Publications

Based on the research that Center programs conduct we have published a number of peer-reviewed articles in scholarly journals such as the American Journal of Public Health and Pediatrics, the official journal of the American Academy of Pediatrics.

(February 2018)

This study evaluated a food insecurity screening and referral program collaboration between Children's Hospital of Philadelphia (CHOP) and Benefits Data Trust (BDT). Of 7,284 families with children under five screened for food insecurity, over one thousand (1,133, 15.6%) reported food insecurity and 630 (55.6%) were referred to a benefits access organization for connection to public benefits and community resources. This study used screening and referral data from CHOP and BDT along with key informant interviews and focus groups with 19 caregivers and 11 clinic staff to evaluate the initiative's effectiveness. Results demonstrate importance of integrated screening and referral consent processes, strong communication, and convenient outreach for families.

(January 2018)

Temporary Assistance for Needy Families (TANF) has limited success in building self-sufficiency, and rarely addresses exposure to trauma as a barrier to employment. The Building Wealth and Health Network's randomized controlled trial tested the effectiveness of financial empowerment combined with trauma-informed peer support against standard TANF programming. Despite high exposure to trauma and adversity, caregivers in the full intervention (financial empowerment and trauma-informed peer support) reported improved self-efficacy and depressive symptoms, and reduced economic hardship compared to the control and partial intervention groups. We conclude that financial empowerment education with trauma-informed peer support is more effective than standard TANF programming at improving behavioral health, reducing hardship, and increasing income. Policymakers may consider adapting TANF to include trauma-informed programming.

(January 2018)

Caregivers of children 0 to 48 months of age were interviewed in five urban medical centers from May 2009 to December 2015. Caregivers reported on the following: caregiver health, maternal depressive symptoms, child’s health, lifetime hospitalizations, developmental risk, and three housing circumstances, which were categorized as being behind on rent in the past 12 months, multiple moves, and child’s lifetime history of homelessness. Of 22,324 families, 34% had at least one of the following adverse housing circumstances: 27% had been behind on rent, 8% had made multiple moves, and 12% had a history of being homeless. We concluded that three forms of housing instability were associated with adverse caregiver and child health among low-income renter households. The American Academy of Pediatrics recommends social screening within health care; providers could consider assessing for behind on rent, multiple moves, and homelessness in high-risk practices.

(October 2017)

This study examined how mothers’ Adverse Childhood Experiences (ACEs) relate to their children’s developmental risk (PEDS) and assessed how the association is mediated through mothers’ depressive symptoms and fair/poor health. Mothers who reported household substance use, mental illness, or an incarcerated household member during childhood were more likely to report at least one child developmental concern on the PEDS. Mothers’ physical and mental health may help to explain the relationship between their own childhood adversity and their children’s development. 

(January 2017)

Depression is a barrier to employment among low-income caregivers receiving Temporary Assistance for Needy Families (TANF), and adverse childhood experiences (ACEs) and exposure to community violence (ECV) are often associated with depression. Using baseline data of 103 TANF caregivers of young children of the Building Wealth and Health Network Randomized Controlled Trial Pilot, this study investigated associations of two forms of employment-related resilience—self-efficacy and employment hope—with exposure to adversity/violence and depression.

(July 2016)

Families with children under age six participating in the Temporary Assistance for Needy Families Program (TANF) must participate in work-related activities for 20 hours per week. However, due to financial hardship, poor health, and exposure to violence and adversity, families may experience great difficulty in reaching self sufficiency.  The purpose of this report is to describe study design and baseline findings of a trauma-informed financial empowerment and peer support intervention meant to mitigate these hardships.

(May 2016)

Exposure to childhood adversity, including abuse, neglect, and household dysfunction, is associated with negative long-term health and economic outcomes. This study used cross-sectional data from 1,255 female caregivers of children under 4 years surveyed in an urban clinical setting to investigate the association between caregivers’ adverse childhood experiences (ACEs) and household and child food insecurity, taking into account depressive symptoms. Depressive symptoms and ACEs were independently associated with household and child food insecurity, and depressive symptoms modified the association between ACEs and household and child food insecurity. Comprehensive policy interventions incorporating nutrition assistance and behavioral health may address intergenerational transmission of disadvantage.

(May 2016)

Household food insecurity is linked with exposure to violence and adversity throughout the life course, suggesting its transfer across generations. Using grounded theory, we analyzed semistructured interviews with 31 mothers reporting household food insecurity where participants described major life events and social relationships. Through the lens of multigenerational interactions, 4 themes emerged: (1) hunger and violence across the generations, (2) disclosure to family and friends, (3) depression and problems with emotional management, and (4) breaking out of intergenerational patterns. After describing these themes and how they relate to reports of food insecurity, we identify opportunities for social services and policy intervention.

(February 2016)

The purpose of this research is to assess food insecurity in low-income households with young children with and without special health care needs (SHCN) and evaluate relationships between child Supplemental Security Income (SSI) receipt and food insecurity. A cross-sectional survey of caregivers was conducted at 5 medical centers. Of 6,724 index children, 81.5% screened negative for SHCN, 14.8% positive for SHCN (no SSI), and 3.7% had SHCN and received SSI. Among households with children with SHCN, those with children receiving, versus not receiving SSI, were more likely to report household but not child food insecurity. Low-income households with young children having SHCN are at risk for food insecurity, regardless of child SSI receipt and household participation in other public assistance programs. Policy recommendations include reevaluation of assistance programs' income and medical deduction criteria for households with children with SHCN to decrease the food insecurity risk faced by these children and their families. 


(August 2015)

Food insecurity is an under-recognized public health crisis in the United States affecting 19.5 percent of households with children and 35.4 percent of female-headed households with children. In 2013, approximately 15.8 million children (21.4%) lived in households that reported food insecurity, and 8.5 million children (23.7%) under age six lived in food insecure households. Lack of public attention and recent decisions by policymakers to cut nutrition assistance programs call into question current efforts to raise awareness and communicate about hunger and its public health impacts. As one contribution, we describe the methods of Witnesses to Hunger, a photovoice and participatory action research model of collaboration with low-income caregivers of young children who participate in nutrition assistance programs and offer solutions to public health professionals, policymakers, and journalists.

(July 2015)

This study among 51 parents of young children under age four investigated how parents that report marginal, low and very low food security characterize how trade-offs associated with food insecurity affect parents' mental health and child well-being. We carried out 51 semi-structured audio-recorded interviews after participants responded to a survey regarding food security status and maternal depressive symptoms. Among participants reporting both food insecurity and depressive symptoms, we identified three primary areas of concern: trade-offs, mental health, and child well-being. Parents described how trade-offs associated with food insecurity have a profound relationship with their mental health and home environment that strongly affects young children. Partnerships between healthcare providers, policymakers, and parents are essential to successfully address and prevent the poor child health outcomes of toxic stress associated with food insecurity and poverty.

(April 2015)

Housing insecurity is a known threat to child health understanding predictors of housing insecurity can help inform policies to protect the health of young children in low-income households. This study sheds light on the relationship between housing insecurity and availability of housing that is affordable to low-income households. We developed a county-level index of availability of subsidized housing needed to meet the demand of low-income households. Our results estimate that if subsidized units are made available to an additional 5% of the eligible population, the odds of overcrowding decrease by 26% and the odds of families making multiple moves decrease by 31%. Both of these are known predictors of poor child health outcomes. Thus, these results suggest that state and federal investments in expanding the stock of subsidized housing could reduce housing insecurity and thereby also improve the health and well-being of young children, including their families’ food security status.

(February 2015)

(Preventing Chronic Disease)

Tobacco advertising is widespread in urban areas with racial/ethnic minority and low-income households that participate in nutrition assistance programs. Tobacco sales and advertising are linked to smoking behavior, which may complicate matters for low-income families struggling with disparate health risks relating to nutrition and chronic disease. We investigated the relationship between the amount and type of tobacco advertisements on tobacco outlets and the outlet type and location. 

Policy makers may be able to mitigate the effects of this disparate expos- ure through tobacco retail licensing, local sign control rules, and SNAP and WIC authorization. 

(January 2015)

(Public Health Nutrition)

Adverse childhood experiences, including abuse, neglect and house-hold instability, affect lifelong health and economic potential. The study investigates how adverse childhood experiences are associated with food insecurity by exploring caregivers’ perceptions of the impact of their childhood adversity on educational attainment, employment and mental health.  Thirty-one mothers of children under the age of four who reporter low or very low household food security were interviewed. Participants described the impact of childhood adverse experiences with emotional and physical abuse/neglect, and household substance abuse, on their emotional health, school performance and ability to maintain employment. In turn, these experiences negatively affected their ability to protect their children from food insecurity.

The associations between mothers’ adverse experiences in childhood and reports of current household food security should inspire researchers, advocates and policy makers to comprehensively address family hardship through greater attention to the emotional health of caregivers. Programs meant to address nutritional deprivation and financial hardship should include trauma-informed approaches that integrate behavioral interventions.

(November 2014)

(Maternal and Child Health Journal)

As many as 3.5 million people experience homelessness yearly. Children are disproportionately impacted; from 2007 to 2010 homelessness among children increased by 448,000–1.6 million children, or one in 45 US children. Homeless children experience increased risk of acute ill- nesses, nutritional deficits, physical trauma, developmental delays, chronic disease, emotional and behavioral problems, poor school attendance, and low academic achievement. An increasing body of evidence identifies pregnancy as a uniquely vulnerable time for children’s lifetime health and development.

The goal of the current analysis is to evaluate whether the recalled birth weight and gestational age of young low- income children whose mothers report homelessness dur- ing pregnancy differ from those recalled by mothers who have neither been homeless during the pregnancy nor within the lifetime of the child, as well as from mothers who were housed throughout pregnancy but became homeless after the child’s birth, which we term postnatal homelessness. A finding that prenatal, but not postnatal, homelessness is associated with adverse birth outcomes would suggest that prenatal homelessness is unique, time- dependent risk factor, rather than a marker for other maternal and social characteristics. 

(March 2012)

(Public Health Nutrition)

Forty women described exposure to violence ranging from fear of violence to personal experiences with rape. Exposure to violence affected mental health, ability to continue school and obtain work with living wages, and subsequently the ability to afford food. Exposure to violence during childhood and being a perpetrator of violence were both linked to very low food security status and depressive symptoms. Ten of seventeen (59 %) participants reporting very low food security described life-changing violence, compared with three of fifteen (20 %) participants reporting low food security and four of twelve (33 %) reporting food security. Examples of violent experiences among the very low food secure group included exposure to child abuse, neglect and rape that suggest exposure to violence is an important factor in the experience of very low food security.

Descriptions of childhood trauma and life-changing violence are linked with severe food security. Policy makers and clinicians should incorporate violence prevention efforts when addressing hunger. 

(Journal of Applied Research on Children, February 2012)

The causes and contexts of food insecurity among children in the U.S. are poorly understood because the prevalence of food insecurity at the child level is low compared to the prevalence of household food insecurity. In addition, caregivers may be reluctant to admit their children may not be getting enough food due to shame or fear they might lose custody of their children.

Based on our ongoing qualitative research with mothers of young children, we suggest that food security among children is related to adverse childhood experiences of caregivers. This translates into poor mental and physical health in adolescence and adulthood, which can lead to inability to secure and maintain meaningful employment that pays a living wage.

In this paper we propose that researchers shift the framework for understanding food insecurity in the United States to adopt a life course approach. This demands we pay greater attention to the lifelong consequences of exposure to trauma or toxic stress—exposure to violence, rape, abuse and neglect, and housing, food, and other forms of deprivation—during childhood. We then describe three case studies of women from our ongoing study to describe a variety of toxic stress exposures and how they have an impact on a woman’s earning potential, her mental health, and attitudes toward raising children. Each woman describes her exposure to violence and deprivation as a child and adolescent, describes experiences with child hunger, and explains how her experiences have shaped her ability to nourish her children. We describe ways in which we can shift the nature of research investigations on food insecurity, and provide recommendations for policy-oriented solutions regarding income support programs, early intervention programs, child and adult mental health services, and violence prevention programs.

(Journal of Applied Research on Children , February 2012)

America’s low-income families struggle to protect their children from multiple threats to their health and growth. Many research and advocacy groups explore the health and educational effects of food insecurity, but less is known about these effects on very young children. Children’s HealthWatch, a group of pediatric clinicians and public health researchers, has continuously collected data on the effects of food insecurity alone and in conjunction with other household hardships since 1998. The group’s peer reviewed research has shown that a number of economic risks at the household level, including food, housing and energy insecurity, tend to be correlated. These insecurities alone or in conjunction increase the risk that a young child will suffer various negative health consequences, including increases in lifetime hospitalizations, parental report of fair or poor health,1 or risk for developmental delays.2 Child food insecurity is an incremental risk indicator above and beyond the risk imposed by household-level food insecurity. The Children’s Healthwatch research also suggests public benefits programs modify some of these effects for families experiencing hardships. This empirical evidence is presented in a variety of public venues outside the usual scientific settings, such as congressional hearings, to support the needs of America’s most vulnerable population through policy change. Children’s HealthWatch research supports legislative solutions to food insecurity, including sustained funding for public programs and re-evaluation of the use of the Thrifty Food Plan as the basis of SNAP benefits calculations. Children’s HealthWatch is one of many models to support the American Academy of Pediatrics’ call to “stand up, speak up, and step up for children.”3 No isolated group or single intervention will solve child poverty or multiple hardships. However, working collaboratively each group has a role to play in supporting the health and well-being of young children and their families.

1. Cook JT, Frank DA, Berkowitz C, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr. 2004;134:1432-1438.

2. Rose-Jacobs R, Black MM, Casey PH, et al. Household food insecurity: associations with at-risk infant and toddler development. Pediatrics. 2008;121:65-72.

3. AAP leader says to stand up, speak up, and step up for child health [news release]. Boston, MA: American Academy of Pediatrics; October 11, 2008. Accessed January 1, 2012.

(American Journal of Public Health, August 2011)

Objectives. We investigated the association between housing insecurity and the health of very young children.
Methods. Between 1998 and 2007, we interviewed 22069 low-income caregivers with children younger than 3 years who were seen in 7 US urban medical centers. We assessed food insecurity, child health status, developmental risk, weight, and housing insecurity for each child’s household. Our indicators for housing insecurity were crowding (>2 people/bedroom or>1 family/residence) and multiple moves (‡2 moves within the previous year).
Results. After adjusting for covariates, crowding was associated with household food insecurity compared with the securely housed (adjusted odds ratio [AOR]=1.30; 95% confidence interval [CI]=1.18, 1.43), as were multiple moves (AOR=1.91; 95% CI=1.59, 2.28). Crowding was also associated with child food insecurity (AOR=1.47; 95% CI=1.34, 1.63), and so were multiple moves (AOR=2.56; 95% CI=2.13, 3.08). Multiple moves were associated with fair or poor child health (AOR=1.48; 95% CI=1.25, 1.76), developmental risk
(AOR 1.71; 95% CI=1.33, 2.21), and lower weight-for-age z scores (–0.082 vs –0.013; P=.02).
Conclusions. Housing insecurity is associated with poor health, lower weight, and developmental risk among young children. Policies that decrease housing insecurity can promote the health of young children and should be a priority.
(Am J Public Health. 2011;101:1508–1514. doi:10.2105/AJPH.2011.300139)

(Pediatrics, July 2010)

The goal of this publication is to develop a brief screen to identify families at risk for food insecurity and to evaluate the sensitivity, specificity, and convergent validity of the screen.

(Pediatrics, May 2010)

The goals of this publication were to generate a cumulative hardship index and to evaluate its association with the well-being of children 4 to 36 months of age without private health insurance.

(Health and Human Rights, May 2009)

When female-headed households and households with children have the highest prevalence of food insecurity and hunger in the US, the participation of low-income mothers in the development and administration of policies is fundamental to the process of ending hunger and improving child wellbeing.

(American Journal of Public Health, March 2009)

We investigated the risk of household food insecurity and reported fair or poor health among very young children who were US citizens and whose mothers were immigrants compared with those whose mothers had been born in the United States.

(Health and Human Rights, January 2009)

Food insecurity is a serious public health problem associated with poorcognitive and emotional development in children and with depression and poor health in adults.

(Pediatrics, October 2008)

The objectives of this study were to develop a clinical indicator of household energy security and assess associations with food security, health, and developmental risk in children less than 36 months of age.

(Pediatrics, January 2008)

In this study, we evaluated the relationship between household food security status and developmental risk in young children, after controlling for potential confounding variables.

(Nutrition Education and Behavior, June 2007)

This qualitative study examined the relationship between health, hunger, and food insecurity among African American women in Philadelphia.


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